Nilai yang didapat pengusul:32X 0,6=19.2

(1)

Lamp C….

LEMBAR

HASIL PENILAIAN SEJAWAT SEBIDANG ATAU PEER REVIEW KARYA ILMIAH: JURNAL ILMIAH

Judul Artikel Ilmiah : Pesticide Exposure and Thyroid Function in Elementary School Children Living in an Agricultural Area, Brebes District, Indonesia

Nama semua penulis : Suhartono, Apoina Kartini, Hertanto Wahyu Subagio, Budiyono, Agustini Utari, Suratman, Mateus Sakundarno

Status Pengusul (coret yg tidak perlu) : Penulis Utama/ Penulis Utama & Korespondensi/Penulis Korespondensi/

Penulis Anggota Status Jurnal:

 Nama Jurnal : The International Journal of Occupation and Environmental Medicine

 Tahun terbit/Vol/No/halaman : 2018/Vol 9/No 3/halaman 137-144

 Edisi (bulan, tahun) : Juli 2018

 ISSN : P: 2008-6520 O: 2008-6814

 DOI : 10.15171/ijoem.2018.1207

 Alamat WEB Jurnal/ Proceeding : https://www.theijoem.com/ijoem/index.php/ijoem/article/view/1207

 Terindex di : MEDLINE (Index Medicus); Clarivate Analytics (formerly ISI) Web of Science, and Web of Knowledge; Scopus; EMBASE/Excerpta Medica; EBSCO;

CINAHL; CAB Abstracts; Global Health; ISC; HINARI; Ulrichs Global Serials Directory; DOAJ; and Index Medicus for the EMR; archived by PubMed Central (PMC).

Kategori Publikasi (beri tanda V yang sesuai)

Jurnal Internasional [ ] Jurnal internasional bereputasi & memiliki impact factor [√] Jurnal internasional bereputasi, Q3=SJR 0,46

[ ] Jurnal Internasional

Jurnal Nasional [ ] Jurnal Nasional Terakreditasi Dikti Peringkat 1 atau 2

[ ] Jurnal Nasional berbahasa Inggris Terindeks CABI atau Copernicus, atau Berbahasa Inggris Terkreditasi Peringkat 3 atau 4

[ ] Jurnal Nasional berbahasa Indonesia Terakreditasi peringkat 3 atau 4 [ ] Jurnal Nasional

Hasil Penilaian Peer Review:

No Komponen yang dinilai Nilai Maksimal Artikel

Jurnal internasional bereputasi, Q3

Nilai yang didapat artikel

a Kelengkapan unsur isi artikel (10 %) 4 3.2

b Ruang lingkup & kedalaman pembahasan (30 %) 12 9.3

c Kecukupan dan kemutahiran data/informasi dan metodologi (30 %)

12 9.6

d Kelengkapan unsur dan kualitas jurnal (30%) 12 9.9

Nilai Total 40 32

Nilai yang didapat pengusul: 32 X 0,6 =19.2

Catatan Penilaian artikel oleh Reviewer

a Kelengkapan unsur isi artikel State of art dalam introduction sudah baik, introduction, method lengkap, result sesuai dengan method dengan analisa statistik, kesimpulan sesuai menampilkan temuan yang menarik.

b Ruang lingkup & kedalaman pembahasan Hasil Prevalence Ratio (PR) =5.2 ditampilkan sedangkan p= 0.05, sesuai.

Hasil yang sesuai dengan tujuan dibahas dan penulis berusaha memberikan alasan secara scientific dan temuan yang ada referensi yang disitasi mencukupi. Keterbatasan studi dengan desain cross-sectional perlu dipertajam, terutama terkait kajian temporality (paparan mendahului outcome).

c Kecukupan dan kemutahiran data/informasi dan metodologi

Kesesuaian tujuan, metodologi telah dijabarkan dengan lengkap interpretasi hasil/nilai sudah jelas. Pengukuran variabel paparan pestisida menggunakan metode laboratorium (urin) meningkatkan validitas data.

Etika dan penulisan content lengkap.

d Kelengkapan unsur dan kualitas jurnal Kelengkapan unsur dan kualitas terbitas memadai, mengingat penerbit adalah Q3 dengan SJR 0.46.

(2)

Semarang,13 April 2020 Reviewer 1

Prof. Dr. dr. Tri Indah Winarni, MSi.Med, PA.

NIP 196605101997022001

Unit kerja: Fakultas Kedokteran UNDIP

(3)

Lamp C…..

LEMBAR

HASIL PENILAIAN SEJAWAT SEBIDANG ATAU PEER REVIEW KARYA ILMIAH: JURNAL ILMIAH

Judul Artikel Ilmiah : Pesticide Exposure and Thyroid Function in Elementary School Children Living in an Agricultural Area, Brebes District, Indonesia

Nama semua penulis : Suhartono, Apoina Kartini, Hertanto Wahyu Subagio, Budiyono, Agustini Utari, Suratman, Mateus Sakundarno

Status Pengusul (coret yg tidak perlu) : Penulis Utama/ Penulis Utama & Korespondensi/Penulis Korespondensi/

Penulis Anggota Status Jurnal:

 Nama Jurnal : The International Journal of Occupation and Environmental Medicine

 Tahun terbit/Vol/No/halaman : 2018/Vol 9/No 3/halaman 137-144

 Edisi (bulan, tahun) : Juli 2018

 ISSN : P: 2008-6520 O: 2008-6814

 DOI : 10.15171/ijoem.2018.1207

 Alamat WEB Jurnal/ Proceeding : https://www.theijoem.com/ijoem/index.php/ijoem/article/view/1207

 Terindex di : MEDLINE (Index Medicus); Clarivate Analytics (formerly ISI) Web of Science, and Web of Knowledge; Scopus; EMBASE/Excerpta Medica; EBSCO;

CINAHL; CAB Abstracts; Global Health; ISC; HINARI; Ulrichs Global Serials Directory; DOAJ; and Index Medicus for the EMR; archived by PubMed Central (PMC).

Kategori Publikasi (beri tanda V yang sesuai)

Jurnal Internasional [ ] Jurnal internasional bereputasi & memiliki impact factor [√] Jurnal internasional bereputasi, Q3=SJR 0,46

[ ] Jurnal Internasional

Jurnal Nasional [ ] Jurnal Nasional Terakreditasi Dikti Peringkat 1 atau 2

[ ] Jurnal Nasional berbahasa Inggris Terindeks CABI atau Copernicus, atau Berbahasa Inggris Terkreditasi Peringkat 3 atau 4

[ ] Jurnal Nasional berbahasa Indonesia Terakreditasi peringkat 3 atau 4 [ ] Jurnal Nasional

Hasil Penilaian Peer Review:

No Komponen yang dinilai Nilai Maksimal Artikel

Jurnal internasional bereputasi, Q3

Nilai yang didapat artikel

a Kelengkapan unsur isi artikel (10 %) 4 3.2

b Ruang lingkup & kedalaman pembahasan (30 %) 12 11.2

c Kecukupan dan kemutahiran data/informasi dan metodologi (30 %)

12 11.8

d Kelengkapan unsur dan kualitas jurnal (30%) 12 11.8

Nilai Total 40 38

Nilai yang didapat pengusul: 38 X 0,6= 22.8

Catatan Penilaian artikel oleh Reviewer

a Kelengkapan unsur isi artikel Unsur artikel telah memenuhi kaidah penulisan artikel dalam jurnal ilmiah yang dituju, yaitu abstract, introduction, material and methods, results, discussion, acknowledgments, references.

b Ruang lingkup & kedalaman pembahasan Pembahasan artikel sudah cukup baik, dengan menggunakan cukup referensi sebagai acuan yaitu 31 referensi. Diskusi sebaiknya juga memasukkan kemungkinan jenis pestisida lain, selain organopospat, sebagai penyebab terjadinya gangguan fungsi tiroid pada anak di lokasi penelitian. Namun, secara umum kajian teori (biological plausibility) sudah dibahas dengan baik di halaman 142

Terdapat 7 artikel yang kurang update (terbit melebihi 10 tahun terakhir).

c Kecukupan dan kemutahiran data/informasi dan metodologi

Penelitian ini menggunakan pemeriksaan laboratorium metabolit pestisida dalam urin subjek untuk menentukan adanya pajanan pestisida, sehingga validitas data lebih baik. Hasil pemeriksaan metabolit sebaiknya menggunakan skala ratio (tidak dikategorikan), sehingga analisis hubungan pajanan pestisida dengan fungsi tiroid (kadar TSH dan FT4) dapat menggunakan uji korelasi dan hubungan dosis respons dapat dibuktikan dengan lebih baik.

Secara umum aspek penyajian data dan metode penelitian cukup baik.

d Kelengkapan unsur dan kualitas jurnal Artikel diterbitkan oleh jurnal bereputasi dengan Q3 memiliki SJR 0.46 dan terindex scopus coverage 2010–2019.

(4)

Semarang, 18-4- 2020 Reviewer 2

Prof. Dr. dr. Banundari Rachmawati, Sp. PK(K) NIP. 196006061988112002

Unit kerja : Fakultas Kedokteran UNDIP

(5)

Document details

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Pesticide exposure and thyroid function in elementary school children living in an agricultural area , Brebes District , Indonesia

(Article) (Open Access)

, , , , , ,

Department of Environmental Health, Faculty of Public Health, Diponegoro University, Semarang, Indonesia Department of Public Health Nutrition, Faculty of Public Health, Diponegoro University, Semarang, Indonesia Department of Nutrition, Faculty of Medicine, Diponegoro University, Semarang, Indonesia

Abstract

Background: Children living in agricultural areas are at risk of exposure to pesticides due to their involvement in agricultural activities. Pesticides are one of the chemicals classiﬁed as endocrine disrupting chemicals. Objective: To examine the association between exposure to organophosphate pesticides and the occurrence of thyroid dysfunction in children . Methods: This cross-sectional study was conducted on 66

children in two elementary schools located in an agricultural area in Brebes District , Indonesia , in 2015. To determine the pesticide exposure history, we analyzed urine samples and completed a questionnaire.

Meanwhile, thyroid function tests were performed. Results: Organophosphate pesticide metabolites were detected in urine samples of 15 (23%) of 66 children . Thyroid stimulating hormone (TSH) levels >4.5 μIU/mL were detected in 24 (36%) children . Free thyroxine (FT4) levels of all participants were normal. The mean TSH level

in children with positive urinary organophosphate pesticide metabolites (7.74 µIU/ mL) was signiﬁcantly (p=0.005) higher than that in those who were negative (4.34 µIU/mL). The prevalence of hypothyroidism in

children with positive urinary organophosphate pesticide metabolites (67%) was signiﬁcantly higher than that in those who were negative (27%; PR 2.4, 95% CI 1.4 to 4.3). Conclusion: A history of pesticide exposure could be used as a risk factor for the occurrence of thyroid dysfunction in children living in agricultural areas. © 2018, NIOC Health Organization. All rights reserved.

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Author keywords

Agriculture Child Hypothyroidism Indonesia Organophosphates Pesticides Thyroid function test

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Open Access International Journal of Occupational and Environmental Medicine

Volume 9, Issue 3, July 2018, Pages 137-144

Suhartono, S.â  Kartini, A.^b Subagio, H.W.^c Budiyonoâ Utari, A.^d Suratman, S.ê Sakundarno, M.^f,g 

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Hypothyroidism | Thyroid Gland | Subclinical hyperthyroidism

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Assessment of the endocrine- disrupting eﬀects of diethyl phosphate, a nonspeciﬁc metabolite of organophosphorus pesticides, by in vivo and in silico approaches

Yang, F.-W. Zhao, G.-P. Ren, F.- Z.

The relationship between pesticide exposure and umbilical serum igf-1 levels and low-birth weight: A case-control study in brebes, indonesia

Widyawati, S.A. Suhartono, S.

Mexitalia, M.

Thyroxine modulation of immune toxicity induced by mixture pesticides mancozeb and ﬁpronil in mice

Bano, F. Mohanty, B.

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From April to May, 2018, mushroom poisoning took lives of 19 in west and northwestern provinces of Iran. (see the Article)

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Raúl Gomero, Ludy Murguía, Livia Calizaya, Christian R Mejia, Arnaldo Sánchez-B

Pesticide Exposure and Thyroid Function in Elementary School Children Living in an Agricultural Area, Brebes District, Indonesia

Suhartono Suhartono, Apoina Kartini, Hertanto Wahyu Subagio, Budiyono Budiyono, Agustini Utari, Suratman Suratman, Mateus Sakundarno

Aberrant DNA Methylation of Two Tumor Suppressor Genes, p14^ARF and p15^INK4b, after Chronic Occupational Exposure to Low Level of Benzene

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Pesticide Exposure and Thyroid Function in Elementary School Children Living in an Agricultural Area, Brebes District, Indonesia

Suhartono Suhartono, Apoina Kartini, Hertanto Wahyu Subagio, Budiyono Budiyono, Agustini Utari, Suratman Suratman, Mateus Sakundarno

Abstract

Background: Children living in agricultural areas are at risk of exposure to pesticides due to their involvement in agricultural activities. Pesticides are one of the chemicals classified as endocrine disrupting chemicals.

Objective: To examine the association between exposure to organophosphate pesticides and the occurrence of thyroid dysfunction in children.

Methods: This cross-sectional study was conducted on 66 children in two elementary schools located in an agricultural area in Brebes District, Indonesia, in 2015. To determine the pesticide exposure history, we analyzed urine samples and completed a questionnaire. Meanwhile, thyroid function tests were performed.

Results: Organophosphate pesticide metabolites were detected in urine samples of 15 (23%) of 66 children. Thyroid stimulating hormone (TSH) levels >4.5 μIU/mL were detected in 24 (36%) children. Free thyroxine (FT4) levels of all participants were normal. The mean TSH level in children with positive urinary organophosphate pesticide metabolites (7.74 μIU/ mL) was significantly (p=0.005) higher than that in those who were negative (4.34 μIU/mL). The prevalence of hypothyroidism in children with positive urinary organophosphate pesticide metabolites (67%) was significantly higher than that in those who were negative (27%; PR 2.4, 95% CI 1.4 to 4.3).

Conclusion: A history of pesticide exposure could be used as a risk factor for the occurrence of thyroid dysfunction in children living in agricultural areas.

Keywords

Pesticides; Thyroid function test; Child; Agriculture; Indonesia; Organophosphates; Hypothyroidism

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Case Series

Abstract

From April 28 to May 28, 2018, more than 1200 patients with impression of mushroom poisoning were referred to hospital emergency departments in 13 west and northwestern provinces, Iran; 112 (8.9%) patients were hospitalized and 19 were expired (ie, a fatality rate of 1.5%). The outbreak began in Kermanshah province with increasing number of patients presenting with severe abdominal pain, nausea, vomiting, and diarrhea soon after consumption of wild mushrooms. Lepiota brunneioncarnata, Hypholoma fascicalare, and Coprinopsis atramentaria have been involved in this outbreak. To prevent similar outbreaks, raising public awareness about risky behaviors of collecting and consuming wild self-picked mushrooms is of paramount importance. Herein, we present our experience with this outbreak.

Keywords: Mushroom poisoning; Disease outbreaks; Epidemics; Iran

Outbreak of Mushroom Poisoning in Iran:

April–May, 2018

Kambiz Soltaninejad

Department of Foren- sic Toxicology, Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran

Correspondence to Dr. Kambiz Soltanine- jad, Associate Profes- sor, Department of Forensic Toxicology, Le- gal Medicine Research Center, Legal Medicine Organization, Khayyam Ave, Behesht St, Tehran 1114795113, Iran Tel: +98-21-5561-3731 E-mail: kamsoltanine- [email protected] Received: Jun 5, 2018 Accepted: Jun 13, 2018

Cite this article as: Soltaninejad K. Outbreak of mushroom poisoning in Iran: April–May, 2018. Int J Occup Environ Med 2018;9:152-156. doi: 10.15171/ijoem.2018.1380

Outbreak

F

rom April 28 to May 28, 2018, more than 1200 patients with impression of intoxication due to ingestion of wild poisonous mushrooms were referred to hospital emergency departments in 13 west and northwestern provinces, Iran. Of these 1247 patients, 112 (8.9%) were hospitalized; 19 were expired, translating to a fatality rate of 1.5% (95% CI 0.8% to 2.2%) (Table 1).^1-3

The outbreak began on April 28 in Ker- manshah province with increasing number of patients presenting with severe abdominal pain, nausea, vomiting, and diarrhea soon after consumption of wild mushrooms. After 10 days, 46 patients with mushroom toxicity including one fatality, were reported in Kermanshah.

Thereafter, several health care centers, mostly in western and northwestern provinces, reported hundreds of patients with impression of mushroom poisoning ad-

mitted to their Emergency Departments.

On suspicion of facing an epidemic of my- cetism in these provinces, the Ministry of Health and Medical Education prepared a guideline on the diagnosis and treatment of toxic mushroom poisoning.⁴

All poisonings were accidental and ingestion with suicidal, recreational or crim- inal intent was not reported in anyone.

Accidental poisoning occurred in those who ingested self-picked wild mushrooms from suburban areas, farms, gardens, hillsides and forest or purchased the wild mushrooms (as edible mushrooms) from local markets of these provinces. In May 2018, due to optimal climatic conditions for growth of mushrooms, ie, plenty of rainfall, sunlight, optimum environmental temperature (27–31 °C), and soil mois- ture in the western and northwestern Iran, an extensive growth of edible and toxic mushrooms was observed. Self-harvesting of wild mushrooms and their sale in local markets in western and northwestern

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www.theijoem.com Vol 9, Num 3; July, 2018 113

Original Article

Abstract

Background: Dental staff may be at increased risk of adverse pregnancy outcome secondary to their chronic exposure to mercury.

Objective: To investigate obstetric outcome among dental staff and explore the oxidative stress induced by mercury exposure.

Methods: A cohort of 64 pregnant dental staff (exposed group) and 60 pregnant employees (non-exposed group) were studied. Urinary mercury level and blood antioxidant activity were measured. Participants were followed to assess their obstetric outcome.

Results: The exposed group had a higher mean urinary mercury level and a lower blood antioxidant activity during the three trimesters compared to non-exposed group (p<0.001).

Women in the exposed group were experienced more frequently spontaneous abortion and pre-eclampsia (p<0.05). Babies born to the women in the exposed group tended to be smaller for gestational age compared to those of non-exposed group (p<0.001).

Conclusion: Pregnant dental staff suffered higher odds of developing spontaneous abortion and pre-eclampsia and giving birth to babies smaller for gestational age. This may be linked to oxidative stress induced by exposure to mercury.

Keywords: Dental staff; Pregnancy outcome; Mercury poisoning; Oxidative stress; Anti- oxidants; Glutathione peroxidase; Superoxide dismutase

Mercury-induced Oxidative Stress May Adversely Affect Pregnancy Outcome among Dental Staff: A Cohort Study

Aziza El-Badry

¹

, Mohamed Rezk

²

, Hanan El-Sayed

³

¹Department of Public Health and Community Medicine

²Department of Obstet- rics and Gynecology

³Department of Pediatrics, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Correspondence to Aziza El-Badry, MD, 25 Yasin Abdelghafar St, Shibin El-Kom City, Menoufia Governorate, Egypt

Tel: +20-100-623-7186 E-mail: m_rezk9207@

yahoo.com

Received: Oct 19, 2017 Accepted: Feb 21, 2018 Cite this article as: El-Badry A, Rezk M, El-Sayed H. Mercury-induced oxidative stress may adversely affect preg-

nancy outcome among dental staff: A cohort study. Int J Occup Environ Med 2018;9:113-119. doi: 10.15171/

ijoem.2018.1181

Introduction

M

ercury has been used for over two centuries as a dental restorative filling material. Despite worldwide repeated safety concerns, dental amalgam is still used in low- and middle- income countries as its alternatives are more expensive and less durable.^1-3 Dental staff members are constantly exposed to mercury vapor, which is readily absorbed

through the skin and lungs and excreted by the kidneys.^4,5

Adverse pregnancy outcome has been reported in previous studies with increased rates of spontaneous abortion and congenital malformations among women working in dental clinics.⁶ This finding is, however, contradicted by other studies.^7,8 A cross-sectional study investigated the effect of elemental mercury exposure on antioxidative enzymes activities, as a pos-

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Original Article

Abstract

Background: Obesity and overweight are associated with work absenteeism of medical cause. However, there is little knowledge on the relationship between incremental body mass index (BMI) and absenteeism.

Objective: To assess the effect of annual increase in BMI on amount of prolonged absenteeism.

Methods: Data from a longitudinal historical cohort of workers of a mining camp in Peru between 2006 and 2014 were used for the analysis. Prolonged absenteeism of 30 days or more in one year was chosen as the dependent variable; annual increase in BMI was considered as the explanatory variable. Regression analysis with generalized estimating equation was used to determine the relative risk adjusted for age, sex and type of work.

Results: There were 1347 cases of medical leave reported with a median of 6 days. Of all cases of medical leave, 11% of those who had an annual increase in BMI and 6% of those who maintained their BMI were cases of prolonged absenteeism. Prolonged absenteeism significantly increased in workers who had an annual increment in BMI (adj RR 1.16, 95% CI 1.05 to 1.29).

Conclusion: The annual increase in BMI was marginally associated with prolonged absenteeism. Temporal increment in BMI, regardless of the baseline BMI, may be an independent determinant of the work absenteeism of medical cause.

Keywords: Body mass index; Absenteeism; Obesity; Sick leave

Association between the

Increase in Body Mass Index and Medical Absenteeism in a Peruvian Mining Population

Raúl Gomero

¹

, Ludy Murguía

²

, Livia Calizaya

³

, Christian R. Mejia

⁴

, Arnaldo Sánchez-B

⁵

1Environmental and Occupational Medicine, Faculty of Medicine, Cayetano Heredia University, Lima, Peru

2Faculty of Medicine, Cayetano Heredia Uni- versity, Lima, Peru

3Faculty of Medicine, Peruvian University of Applied Science, Lima, Peru

4Occupational Health and Epidemiology Program, Faculty of Medicine, Continental University, Huancayo, Peru

5Faculty of Medicine, University of British Columbia, British Columbia, Canada

Correspondence to Arnaldo Sanchez-B, MD, 2775 Laurel St, Vancouver V5Z 1M9, BC, Canada Tel: +1-703-261-4646 E-mail: arnaldo.sb@

alumni.ubc.ca Received: Nov 8, 2017 Accepted: Jul 24, 2018 Cite this article as: Gomero R, Murguía L, Calizaya L, et al. Association between the increase in body mass

index and medical absenteeism in a Peruvian mining population. Int J Occup Environ Med 2018;9:129-136. doi:

10.15171/ijoem.2018.1201

Introduction

T

he World Health Organization (WHO) considers the workplace as a priority for health promotion given the opportunity to decrease the frequency of not only occupational medical conditions, but also chronic preventable diseases.¹ Health promotion at workplace has

involved programs to address overweight and obesity to improve workers' health and ameliorate the economic cost of obesity.^2,3 Worldwide, in the past decades, there has been an increase in the prevalence of obesity in the economically active adult population,⁴ with a corresponding increase in the incidence of associated conditions such as diabetes, heart disease, cancer,

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Letter to the Editor

Comments on the

Measurement of Lung Cancer Tumor Markers in Workers of a Glass Wool Company

Correspondence: Nata- lie Suder Egnot, DrPH, Health Scientist, Cardno ChemRisk, USA E-mail: natalie.egnot@

cardno.com

Received: May 18, 2018 Accepted: May 19, 2018 Cite this article as: Marsh GM, Bernal A, Egnot NS, et al. Comments on the measurement of lung cancer

tumor markers in workers of a glass wool company. Int J Occup Environ Med 2018;9:157-159. doi:10.15171/

ijoem.2018.1356

Dear Editor,

W

e read with interest the article on the measurement of lung cancer tumor markers in a group of workers exposed to respirable synthet- ic vitreous fiber (SVF) and dust, recently published in the IJOEM.¹ The authors re- port on the relationship between exposure to respirable SVF and serum levels of two biomarkers implicated in lung cancer, sug- gesting that elevations in these biomarkers support a relationship between SVF exposure and lung cancer. However, several methodological and interpretational issues in their evaluation call the authors' con- clusions into question. For example, the authors excluded smokers only from the study's control group, thus any effects of smoking would differentially influence any statistical comparisons made between the cases and controls. Moreover, the authors' basic two-sample statistical comparisons did not enable adjustment for the potential confounding factors including known risk factors for cancer such as age, alcohol use, and family history. In the Introduction of their paper, the authors also grossly mis- interpreted the overwhelmingly negative scientific literature as providing evidence of a positive association between exposure

to SVF and several lung diseases including lung cancer and pleural mesothelioma.

In addition to methodological flaws, the authors misrepresented the mean- ingfulness of the reported elevations in biomarker levels. The authors suggest that these biomarkers, carcinoembryonic an- tigen (CEA) and cytokeratin 19 fragment (CYFRA 21-1), are useful diagnostic and prognostic tools for lung cancer. Based on the literature cited, it is clear that nei- ther CEA nor CYFRA 21-1 consistently displays diagnostic value.^2,3 Furthermore, these biomarkers are not specific to lung cancer. Nearly all of the observed associa- tions reported in this study¹ attenuate after excluding smokers from the analysis and are no longer statistically significant.

The main conclusion of the Abtahi, et al, study that remained statistically significant following the exclusion of smokers, is based on findings from a stratified analysis comparing workers by duration of em- ployment (greater vs less than nine years).

Age is a known prognostic factor for lung cancer and a possible source of hetero- geneity in biomarker levels.^4,5 Therefore, the reported higher levels of CYFRA 21-1 among workers employed by the glass fiber manufacturing facility for greater than nine years may simply be due to the older

Gary M. Marsh, Autumn Bernal, Natalie Suder Egnot, Marisa Kreider

Cardno ChemRisk, San Francisco, California, USA